Probe EUS for the diagnosis of invasion depth in superficial esophageal cancer: a comparison between a jelly-filled method and a water-filled balloon method

A deep learning-based system to identify originating mural layer of upper gastrointestinal submucosal tumors under EUS

Background and Objective

EUS is the most accurate procedure to determine the originating mural layer and subsequently select the treatment of submucosal tumors (SMTs). However, it requires superb technical and cognitive skills. In this study, we propose a system named SMT Master to determine the originating mural layer of SMTs under EUS.

Materials and Methods

We developed 3 models: deep convolutional neural network (DCNN) 1 for lesion segmentation, DCNN2 for mural layer segmentation, and DCNN3 for the originating mural layer classification. A total of 2721 EUS images from 201 patients were used to train the 3 models. We validated our model internally and externally using 283 images from 26 patients and 172 images from 26 patients, respectively. We applied 368 images from 30 patients for the man-machine contest and used 30 video clips to test the originating mural layer classification.

Results

In the originating mural layer classification task, DCNN3 achieved a classification accuracy of 84.43% and 80.68% at internal and external validations, respectively. In the video test, the accuracy was 80.00%. DCNN1 achieved Dice coefficients of 0.956 and 0.776 for lesion segmentation at internal and external validations, respectively, whereas DCNN2 achieved Dice coefficients of 0.820 and 0.740 at internal and external validations, respectively. The system achieved 90.00% accuracy in classification, which is comparable with that of EUS experts.

Conclusions

Our proposed system has the potential to solve difficulties in determining the originating mural layer of SMTs in EUS procedures, which relieves the EUS learning pressure of physicians.

Diagnostic Performance of Endoscopic Ultrasonography with Water-Filled Balloon Method for Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

Endoscopic ultrasonography (EUS) is a commonly used tool for preoperative depth diagnosis of superficial esophageal squamous cell carcinoma (ESCC). Probing EUS using the water-filled balloon method is a simple and safe examination.

AIM

The aim of this study was to clarify the diagnostic performance of EUS with the water-filled balloon method for superficial ESCC compared to magnifying narrow-band imaging (ME-NBI).

METHODS

We retrospectively examined 403 lesions in 393 consecutive patients diagnosed with ESCC and evaluated them with ME-NBI and EUS. Clinicopathological findings were collected, and the accuracy of the preoperative diagnosis was compared between ME-NBI and EUS-B. EUS examiners were not blinded to prior ME-NBI results, and EUS results may have been influenced by ME-NBI results.

RESULTS

The pathological tumor depth of the EP/LPM in 152 lesions, MM/SM1 in 130 lesions, and deep submucosa (SM2/SM3) in 121 lesions was examined. The proportion of total lesions with an accurate diagnosis was significantly higher in EUS than in ME-NBI (67.7% versus 62.0%, P = 0.015). When analyzed by clinical depth diagnosis using ME-NBI, the proportion of lesions with an accurate diagnosis was significantly higher for EUS in MM/SM1 (55.7% versus 46.1%, P = 0.033). The sensitivity was significantly higher in EUS for SM2/SM3 lesions (76.0% versus 54.5%, P < 0.001). The accuracy and specificity of EUS, which differentiate MM/SM1 from EP/LPM or SM2/SM3, were significantly higher than those of ME-NBI. The median endoscopic ultrasonography procedure time was approximately 6.5 min.

CONCLUSIONS

EUS with the water-filled balloon method is a safe and straightforward method that can be performed on lesions clinically diagnosed as MM/SM1 using ME-NBI. We retrospectively reviewed lesions in patients diagnosed with ESCC and evaluated them using magnifying endoscopy with narrow-band imaging (ME-NBI) and endoscopic ultrasound using the water-filled balloon method (EUS-B). We conclude that EUS-B can increase the diagnostic accuracy.

Endoscopic resection for local residual or recurrent cancer after definitive chemoradiotherapy or radiotherapy for esophageal squamous cell carcinoma

Chemoradiotherapy (CRT) and radiotherapy (RT) are treatment options for esophageal squamous cell carcinoma (ESCC), but local residual/recurrent cancer after CRT/RT is a major problem. Endoscopic resection (ER) is an effective treatment option for local residual/recurrent cancer. To ensure the efficacy of ER, complete removal of endoscopically visible lesions with cancer-free vertical margins is desired. This study aimed to identify the endoscopic parameters associated with the complete endoscopic removal of local residual/recurrent cancer. In this single-center, retrospective study, we used a prospectively maintained database to identify esophageal lesions that were diagnosed as local residual/recurrent cancer after CRT/RT and treated by ER between January 2012 and December 2019. We evaluated the associations of endoscopic R0 resection with findings on conventional endoscopy and endoscopic ultrasonography (EUS). In total, 98 lesions (83 cases) were identified from our database. The rate of endoscopic R0 resection was higher for flat lesions (100% versus 77%, P = 0.00014). EUS was performed for 24 non-flat lesions, and endoscopic R0 resection was achieved for 94% of lesions with an uninterrupted fifth layer. Flat lesions on conventional endoscopy and lesions with an uninterrupted fifth layer on EUS are good candidates for ER.

Application of endoscopic ultrasonography for detecting esophageal lesions based on convolutional neural network

BACKGROUND

A convolutional neural network (CNN) is a deep learning algorithm based on the principle of human brain visual cortex processing and image recognition.

AIM

To automatically identify the invasion depth and origin of esophageal lesions based on a CNN.

METHODS

A total of 1670 white-light images were used to train and validate the CNN system. The method proposed in this paper included the following two parts: (1) Location module, an object detection network, locating the classified main image feature regions of the image for subsequent classification tasks; and (2) Classification module, a traditional classification CNN, classifying the images cut out by the object detection network.

RESULTS

The CNN system proposed in this study achieved an overall accuracy of 82.49%, sensitivity of 80.23%, and specificity of 90.56%. In this study, after follow-up pathology, 726 patients were compared for endoscopic pathology. The misdiagnosis rate of endoscopic diagnosis in the lesion invasion range was approximately 9.5%; 41 patients showed no lesion invasion to the muscularis propria, but 36 of them pathologically showed invasion to the superficial muscularis propria. The patients with invasion of the tunica adventitia were all treated by surgery with an accuracy rate of 100%. For the examination of submucosal lesions, the accuracy of endoscopic ultrasonography (EUS) was approximately 99.3%. Results of this study showed that EUS had a high accuracy rate for the origin of submucosal lesions, whereas the misdiagnosis rate was slightly high in the evaluation of the invasion scope of lesions. Misdiagnosis could be due to different operating and diagnostic levels of endoscopists, unclear ultrasound probes, and unclear lesions.

CONCLUSION

This study is the first to recognize esophageal EUS images through deep learning, which can automatically identify the invasion depth and lesion origin of submucosal tumors and classify such tumors, thereby achieving good accuracy. In future studies, this method can provide guidance and help to clinical endoscopists.

Positive predictive value of the clinical diagnosis of T1a-epithelial/lamina propria esophageal cancer depends on lesion size

OBJECTIVES

Endoscopic resection (ER) is a minimally invasive treatment for esophageal squamous cell carcinoma (ESCC). However, stricture may develop after ER for widespread lesions. Application of ER is justified if these cancers are pathological T1a-epithelial/lamina propria (pEP/LPM) cancers that can be cured by ER. We conducted a study to clarify the association between pathological invasion depth and lesion size or circumference in clinical (c) EP/LPM cancers.

METHODS

From our database, we identified patients diagnosed with cEP/LPM ESCC via endoscopic examination who underwent endoscopic or surgical tumor resection. The accuracy of the cEP/LPM ESCC diagnosis was determined by histologically diagnosing cancer invasion depth as a reference standard.

RESULTS

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The positive predictive value (PPV) classified according to lesion sizes of ≤25, 26-49, and ≥50 mm was 95.8% (981/1024 lesions), 89.7% (191/213 lesions), and 67.6% (23/34 lesions), respectively. PPV according to the circumferential extent of <3/4, ≥3/4, and <1, and whole was 94.6% (1164/1230 lesions), 75.0% (24/32 lesions), and 77.8% (7/9 lesions), respectively. In multivariate analysis, the PPV of cEP/LPM ESCC was significantly associated with lesion size (P < 0.001) and male sex.

CONCLUSIONS

Between January 2015 and December 2019, 1271 cancer patients were diagnosed with cEP/LPM ESCC, of which 1195 (94.0%) were correctly diagnosed with pEP/LPM cancer. The PPV of cEP/LPM ESCC was related to lesion size. Treatment should be determined considering the high risk of cancer invasion into the muscularis mucosa or deeper in cEP/LPM cancers with a lesion size of ≥50 mm.

Current status of endoscopic detection, characterization and staging of superficial esophageal squamous cell carcinoma

BACKGROUND

This review focuses on the current status of endoscopic detection, characterization and tumour category staging of oesophagealsquamous cell carcinoma.

DETECTION

The diagnostic yield of white-light imaging is limited and narrow-band imaging has demonstrated a better performance for detecting oesophageal cancer. Narrow-band imaging has also shown similar sensitivity and superior specificity to iodine staining.

CHARACTERIZATION

Accurate differentiation between cancerous and non-cancerous lesions can be achieved by magnifying narrow-band imaging or iodine staining with confirmation of a pink-colour sign. A per-patient analysis of a randomized study showed similar sensitivities, specificities and overall accuracies of magnifying narrow-band imaging and iodine staining of 82.2%, 95.1% and 91.2%, and 80.5%, 94.3% and 90.5%, respectively.

TUMOUR-STAGING

The diagnostic capability of endoscopic ultrasonography after conventional and narrow-band imaging in terms of tumour depth was evaluated in a multicentre prospective study. Endoscopic ultrasonography did not significantly improve the accuracy for distinguishing between mucosal or submucosal microinvasive cancer and deeper cancers from 72.9 to 74.0%, suggesting that additional endoscopic ultrasonography did not improve the diagnostic accuracy. In addition, endoscopic ultrasonography increased the incidence of overdiagnosis, defined as a diagnosis of cancer depth greater than the actual depth, by 6.6%. The risk of overdiagnosis by endoscopic ultrasonography was reconfirmed in two systematic reviews.

CONCLUSIONS

Narrow-band imaging is currently considered as the standard modality for the detection and characterization of oesophageal cancer. The risk of overdiagnosis should be considered when applying endoscopic ultrasonography for the evaluation of tumour invasion depth of superficial oesophageal squamous cell carcinoma.

Usefulness of Endoscopic Ultrasound with the Jelly-Filling Method for Esophageal Varices

Although the importance of endoscopic ultrasound (EUS) for esophageal varices (EVs) has been demonstrated, it is difficult to obtain sufficient EUS images with the water-filling method because of poor water stagnation in the esophagus. In this study on EVs, we aimed to evaluate the usefulness of the jelly-filling method for EUS. Consecutive patients who underwent EUS for EVs were included. The quality of EUS images, the diagnostic ability of the presence of blood vessels inside and outside the esophageal wall, and the procedure time were compared between the jelly-filling and water-filling methods. Thirty cases were analyzed (jelly-filling method in 13 and water-filling method in 17). The EUS image quality score was significantly higher in the jelly-filling method (jelly vs. water; three points vs. two points, p < 0.001). Additionally, EUS image quality scores in both nonexperts and experts were significantly higher in the jelly-filling method. The diagnostic ability of the presence of perforation veins was significantly higher in the jelly-filling method (jelly vs. water; 100% vs. 52.9%, p = 0.004). However, the procedure time was significantly longer in the jelly-filling method (p = 0.024). In conclusion, EUS using the jelly-filling method for EVs provided sufficient image quality.

Assessment of the Diagnostic Performance of Endoscopic Ultrasonography After Conventional Endoscopy for the Evaluation of Esophageal Squamous Cell Carcinoma Invasion Depth

IMPORTANCE

Distinguishing between mucosal and submucosal cancers is important for selecting the optimal treatment for patients with esophageal squamous cell carcinoma (ESCC); however, standard procedures for diagnosing cancer invasion depth have not yet been determined.

OBJECTIVE

To evaluate the diagnostic performance of endoscopic ultrasonography (EUS) after conventional endoscopy for the evaluation of ESCC invasion depth.

DESIGN, SETTING, AND PARTICIPANTS

This prospective single-arm confirmatory diagnostic study comprising 372 patients with T1 esophageal cancer was conducted at 41 secondary or tertiary hospitals in Japan. Enrollment began on July 20, 2017; patients were enrolled in 2 steps, with the first registration occurring from August 4, 2017, to December 11, 2019, and the second from August 9, 2017, to December 11, 2019. After the completion of all first and second registration examinations, patients received treatment and were followed up for 30 days, with follow-up ending on February 14, 2020. Patients were eligible for inclusion if they had pathologically or endoscopically diagnosed esophageal cancer with T1 clinical depth of invasion.

INTERVENTIONS

In the first registration, nonmagnifying endoscopy (non-ME) and magnifying endoscopy (ME) were used to diagnose cancer invasion depth. In the second registration, patients from the first registration who had cancers invading the muscularis mucosa or submucosa were enrolled and received EUS. After completion of the protocol examinations, patients received treatment with endoscopic resection or esophagectomy. The pathological results of the resected specimens were used as the reference standard for evaluating cancer invasion depth.

MAIN OUTCOMES AND MEASURES

The primary end point was the proportion of overdiagnosis of submucosal cancer (defined as invasion depth >200 μm) after receipt of non-ME and ME, with or without the addition of EUS. The secondary end points were underdiagnosis, sensitivity, and specificity.

RESULTS

Among 372 patients enrolled in the first registration, 371 received non-ME and ME. Of those, 300 patients were enrolled in the second registration, and 293 patients received EUS. A total of 269 patients (217 men [80.7%]; median age, 69 years; interquartile range, 62-75 years) were included in the final analysis. The addition of EUS was associated with a 6.6% increase in the proportion of overdiagnosis (from 16 of 74 patients [21.6%; 95% CI, 12.9%-32.7%] after non-ME and ME to 29 of 103 patients [28.2%; 95% CI, 19.7%-37.9%] after the addition of EUS; 1-sided P = .93). All subgroup analyses found similar increases in overdiagnosis of submucosal cancer. The addition of EUS was associated with a 4.5% reduction in the proportion of underdiagnosis (from 57 of 195 patients [29.2%; 95% CI, 23.0%-36.2%] after non-ME and ME to 41 of 166 patients [24.7%; 95% CI, 18.3%-32.0%] after the addition of EUS). After non-ME and ME, diagnostic sensitivity was 50.4% (95% CI, 41.0%-59.9%), specificity was 89.6% (95% CI, 83.7%-93.9%), and accuracy was 72.9% (95% CI, 67.1%-78.1%). After the addition of EUS, diagnostic sensitivity was 64.3% (95% CI, 54.9%-73.1%), specificity was 81.2% (95% CI, 74.1%-87.0%), and accuracy was 74.0% (95% CI, 68.3%-79.1%).

CONCLUSIONS AND RELEVANCE

This study found that the addition of EUS was not associated with improvements in the diagnostic accuracy of cancer invasion depth. These findings do not support the routine use of EUS after conventional endoscopy for evaluating the invasion depth among patients with T1 ESCC.

Validity of endoscopic resection for clinically diagnosed T1a-MM/T1b-SM1 N0 M0 esophageal squamous cell carcinoma

BACKGROUND

Previous guidelines have not described clear recommendations for performing endoscopic resection (ER) of T1a-muscularis mucosa (MM)/T1b-submucosal (SM1) cancers that have invaded ≤ 200 μm because these are considered to have a non-negligible risk of metastasis based on previous analyses of pathologically diagnosed (p)MM/SM1 cancers. Considering that the indication for ER is determined based on a clinical diagnosis, the applicability of ER should be investigated in clinical (c)MM/SM1 but not pMM/SM1 cancers. This study aimed to evaluate validity of ER for cMM/SM1 cancers.

METHODS

In total, 175 cMM/SM1 esophageal squamous cell carcinoma cases that were endoscopically or surgically resected between January 2008 and December 2018 were identified from a prospectively maintained database. We histologically evaluated resected specimens and divided them into low- (n = 92) and high-risk (n = 83) cancers for metastasis.

RESULTS

Univariate analysis showed that longer tumor length and larger circumferential extent were significantly correlated with high-risk cancer (P < 0.001). Multivariate analysis showed that tumor circumference was an independent predictor of high-risk cancer (P = 0.036). The proportion of low-risk cancers among cases with ≤ 3/4, > 3/4 and < 1, and whole circumferential extent were 59, 17, and 14%, respectively, and the post-ER stricture rates of these groups were 12, 33, and 100%, respectively.

CONCLUSION

ER is the first-line treatment for cMM/SM1 cancers with ≤ 3/4 circumferential extent considering that 59% of cMM/SM1 cancers were low-risk cancers for which ER is mostly curative. ER is not recommended for whole circumferential cMM/SM1 cancers given the low proportion of low-risk cancers and the high risk of stricture after ER.

Diagnostic yield of conventional endoscopy with endoscopic ultrasonography for submucosal invasion of superficial esophageal squamous cell carcinoma: a post hoc analysis of multicenter prospective confirmatory study (JCOG0508)

BACKGROUND

Endoscopic ultrasonography (EUS) is reportedly the reliable modality to predict the depth of esophageal squamous cell carcinoma (ESCC), however, most previous studies are retrospective or single-centered. We aimed to evaluate the diagnostic ability of conventional endoscopy and EUS using the data from a multicenter prospective study of endoscopic resection (ER) followed by chemoradiotherapy for cSM1-2N0M0 ESCC (JCOG0508).

METHODS

All lesions were evaluated as cSM cancer with both conventional endoscopy and EUS before enrollment and judged as cSM1 or cSM2 in real time. We compared the clinical and pathological diagnoses for tumor depth and assessed the positive predictive value (PPV) for pSM (pSM/cSM) as the primary endpoint. We also investigated the clinical factors affecting the pathological depth of SM.

RESULTS

175 lesions were examined, and clinical diagnosis was SM1 in 114 and SM2 in 61 lesions. The pathological diagnoses of the epithelium, lamina propria mucosa, muscularis mucosae, SM1, and SM2 were 3, 31, 55, 17, and 69. The PPV for pSM was 49.1% (86/175) in all lesions, 34.2% (39/114) in cSM1 lesions, and 77.0% (47/61) in cSM2 lesions. Multivariable analysis demonstrated that cSM2 (vs. cSM1, OR 6.79) was an independent clinical factor associated with pSM.

CONCLUSIONS

While the accurate depth diagnosis in cSM ESCC was difficult to make, the clinical diagnosis of SM2 with both conventional endoscopy and EUS was significantly associated with pSM. Furthermore, diagnostic ER could be recommended to confirm the pathological diagnosis especially in cSM1 lesions with both conventional endoscopy and EUS.

Preoperative Diagnosis and Indications for Endoscopic Resection of Superficial Esophageal Squamous Cell Carcinoma

Endoscopic resection (ER) is the mainstay of treatment for superficial esophageal squamous cell carcinoma (SESCC) instead of esophagectomy because of its minimal invasiveness and favorable clinical outcomes. Developments in endoscopic submucosal dissection have enabled en bloc resection of SESCCs regardless of size, thus reducing the risk of local recurrence. Although ER for SESCC is effective, metastasis may subsequently occur. Additionally, extensive esophageal ER confers a risk of postoperative esophageal stricture. Therefore, accurate assessment of the invasion depth and circumferential extent of SESCCs is important in determining the indications for ER. Diagnostic accuracies for SESCC invasion differ between epithelial (EP)/lamina propria (LPM), muscularis mucosa (MM)/submucosal (SM1), and SM2 cancers. ER is strongly indicated for clinically diagnosed (c)EP/LPM cancers because 90% of these are as pathologically diagnosed (p)EP/LPM, which has a very low risk of metastasis. Remarkably, the diagnostic accuracy for cMM/SM1 differs significantly with lateral spread of cancer. Eighty percent of cMM/SM1 cancers with ≤3/4 circumferential spread prove to be pEP/LPM or pMM/SM1, which have very low or low risk of metastasis. Thus, these are adequate candidates for ER. However, given the relatively low proportion of pEP/LPM or pMM/SM1 and high risk of subsequent stricture, ER is not recommended for whole circumferential cMM/SM1 cancers. For cMM/SM1 cancers that involve >3/4 but not the whole circumference, ER should be considered on a lesion-by-lesion basis because the risk of post-ER stricture is not very high, but the proportion of pEP/LPM or pMM/SM1 is relatively low. ER is contraindicated for cSM2 cancers because 75% of them are pSM2, which has high risk of metastasis.

18 F-Fluorodeoxyglucose positron emission tomography can be used to determine the indication for endoscopic resection of superficial esophageal cancer

¹⁸F‐Fluorodeoxyglucose positron emission tomography (FDG‐PET) is a useful imaging modality that reflects the tumor activity. However, FDG‐PET is mainly used for advanced cancer, not superficial cancer. In this study, we investigated the relationship between the superficial tumor depth of esophageal cancer and the FDG uptake to determine the indications for endoscopic resection (ER). From 2009 to 2017, 444 patients with esophageal cancer underwent esophagectomy or endoscopic submucosal dissection (ESD), and 195 patients were pathologically diagnosed with superficial cancer. Among them, 146 patients were examined by FDG‐PET before esophagectomy or ESD. In these 146 patients, the relationship between the pathological tumor depth and FDG uptake was analyzed. The mean maximum standardized uptake value in pT1a‐EP/LPM tumors was 1.362 ± 0.890, that in pT1a‐MM/pT1b‐SM1 tumors was 2.453 ± 1.872, and that in pT1b‐SM2/SM3 tumors was 4.265 ± 3.233 (P < .0001). Among 51 pT1a‐EP/LPM tumors, 10 (19.6%) showed positive detection of FDG. For pT1a‐MM/pT1b‐SM1 and pT1b‐SM2/SM3 tumors, the detection rate was 52.9% (18/34) and 82.0% (50/61), respectively. The detection rate of pT1a‐EP/LPM was significantly lower than in the other two groups (P < .0001). Among 10 FDG‐PET‐positive lesions, only 1 had no apparent reason for PET positivity; however, 9 of 10 had a suitable reason for detectability by PET and inadequacy for ER. Negative detection of superficial esophageal squamous cell carcinoma by FDG‐PET is useful to determine the indication for ER when the tumor depth cannot be diagnosed even after performing magnifying endoscopy with narrow band imaging and endoscopic ultrasonography. When FDG uptake is recognized, a therapeutic modality other than ER should be considered.

Endoscopic prediction model for differentiating upper submucosal invasion (< 200 μm) and beyond in superficial esophageal squamous cell carcinoma

Esophageal endoscopic submucosal dissection (ESD) can be attempted in superficial esophageal squamous cell carcinoma (SESCC) invading the upper submucosal layer (SM1: invasion < 200 μm). This study aimed to determine endoscopic predictive features associated with beyond SM1 invasion in SESCC and establish a predictive model using the identified features. This study retrospectively analyzed 203 esophageal ESD for SESCC. Endoscopic images were reviewed by two endoscopists. Tumors were evaluated for main shape, sizes, and surface characteristics. The association between each endoscopic feature and beyond SM1 invasion was evaluated. Using the significant endoscopic features in multivariate analysis, a predictive model for beyond SM1 invasion in SESCC was established. Among 203 SESCCs, 40 (19.7%) invaded beyond SM1. Multivariate analysis revealed that surface nodularity [odds ratio (OR) 41.340, 95% confidence interval (CI) 8.492–201.252, p < 0.001], surface granularity (OR 18.682, 95% CI 4.818–72.440, p < 0.001), surface unevenness, (OR 4.107, 95% CI 1.160–14.543, p = 0.029), deep depression (OR 27.490, 95% CI 2.897–260.853, p = 0.004), and thick notch (OR 41.701, 95% CI 6.646–261.672, p < 0.001) were independently associated with beyond SM1 invasion. An established model showed an area under the curve of 0.921 with 95% CI 0.881–0.960. The best cut-off value showed the following: sensitivity, 0.85; specificity, 0.83; positive predictive value, 0.55; and negative predictive value, 0.96. In conclusion, endoscopic features can predict beyond SM1 invasion in SESCC. Our prediction model is potentially useful for screening ESD candidates in SESCC.

Catheter probe endoscopic ultrasonography by using cold lubricating jelly-filled method for esophageal subepithelial tumors

Catheter probe endoscopic ultrasonography (C-EUS) by ultrasonographic jelly-filled method has been used to evaluate esophageal subepithelial tumors (SETs). Ultrasonographic jelly is safe on the skin, but its internal safety has not been demonstrated. The jelly stored at room temperature is easily injected into the esophagus through the instrument channel of the endoscope. However, using jelly stored at room temperature remains problematic because the jelly is drained rapidly. We used cold lubricating jelly and an intravenous extension tube to resolve these problems. In this study, we evaluated the safety and efficacy of cold lubricating jelly-filled method. The medical records of patients who underwent C-EUS by using water or cold lubricating jelly-filled method for esophageal SETs from March 2013 to September 2016 in Gangneung Asan hospital were reviewed. Clinical characteristics and EUS findings were evaluated retrospectively. Image quality and procedure time between water and cold lubricating jelly-filled method were compared retrospectively. This study included 138 patients (74 males, 64 females) with esophageal SET with a mean age of 57.1 ± 11.1 years. Thirty-four patients had lesions in the upper esophagus, 58 patients had lesions in the middle esophagus, and 46 patients had lesions in the lower esophagus. The EUS diagnoses were leiomyoma (82.6%), hemangioma (4.3%), extrinsic compressive lesion (3.6%), granulosa cell tumor (2.9%), ectopic calcification (1.4%), cyst (1.4%), lipoma (0.7%), varix (0.7%), and inconclusive lesion (2.2%). The mean image score in the cold lubricating jelly filled-method group was higher than that in the water-filled method group (3.2 ± 0.7 vs. 2.8 ± 0.7, P = 0.002). The procedure time in the cold lubricating jelly filled-method group was shorter than that in the water-filled method group (10 minutes 27 seconds ± 4 minutes 22 seconds versus 13 minutes 20 seconds ± 6 minutes 20 seconds, P = 0.045). No procedure-related complication was observed. C-EUS using the cold lubricating jelly-filled method seems to provide better image quality and shorter procedure time compared with C-EUS using the water-filled method.

Endoscopic imaging modalities for diagnosing invasion depth of superficial esophageal squamous cell carcinoma: a systematic review and meta-analysis

BACKGROUND

Diagnosis of cancer invasion depth is crucial for selecting the optimal treatment strategy in patients with gastrointestinal cancers. We conducted a meta-analysis to determine the utilities of different endoscopic modalities for diagnosing invasion depth of esophageal squamous cell carcinoma (SCC).

METHODS

We conducted a comprehensive search of MEDLINE, Cochrane Central, and Ichushi databases to identify studies evaluating the use of endoscopic modalities for diagnosing invasion depth of superficial esophageal SCC. We excluded case reports, review articles, and studies in which the total number of patients or lesions was <10.

RESULTS

Fourteen studies fulfilled our criteria. Summary receiver operating characteristic curves showed that magnified endoscopy (ME) and endoscopic ultrasonography (EUS) performed better than non-ME. ME was associated with high sensitivity and a very low (0.08) negative likelihood ratio (NLR), while EUS had high specificity and a very high (17.6) positive likelihood ratio (PLR) for the diagnosis of epithelial or lamina propria cancers. NLR <0.1 provided strong evidence to rule out disease, and PLR >10 provided strong evidence of a positive diagnosis.

CONCLUSIONS

EUS and ME perform better than non-ME for diagnosing invasion depth in SCC. ME has a low NLR and is a reliable modality for confirming deep invasion of cancer, while EUS has a high PLR and can reliably confirm that the cancer is limited to the surface. Effective use of these two modalities should be considered in patients with SCC.

TRIAL REGISTRATION

PROSPERO (International Prospective Register of Systematic Reviews); number 42015024462 .

Current status of endoscopic ultrasound for the upper gastrointestinal tract in Asia

We summarize the current status of endoscopic ultrasound (EUS) for the upper gastrointestinal (GI) tract solely in Asia, focusing on the staging of superficial cancers and the diagnosis of submucosal tumors (SMT), by analysis of questionnaire responses and a literature review. EUS for assessing the depth of superficial cancers of the upper GI tract is useful; however, evidence is lacking to support that EUS is superior to other modalities. The current status of EUS varies across different Asian countries, and standardization of the methods used both during the procedure and for depth subclassification is necessary to evaluate the diagnostic accuracy. Although EUS alone is limited in the diagnosis of SMT, EUS-guided fine-needle aspiration is an effective and safe diagnostic tool. Although there is a role for EUS, there are still many limitations both technically and in terms of accessibility.

Predicting the invasion depth of esophageal squamous cell carcinoma: comparison of endoscopic ultrasonography and magnifying endoscopy

OBJECTIVE

Predicting the invasion depth of superficial esophageal squamous cell carcinoma (SESCC) is important when selecting among therapeutic strategies. The aim of this study was to compare magnifying endoscopy with narrow-band imaging (ME-NBI) with endoscopic ultrasonography (EUS) for predicting the depth of tumor invasion in patients with SESCC.

METHODS

This study enrolled 51 patients with SESCC (52 SESCC lesions) who underwent both ME-NBI and EUS at Pusan National University Hospital during 2010-2013. We reviewed the patients' medical records and compared ME-NBI and EUS findings with histopathological results according to clinicopathological factors.

RESULTS

A total of 46 lesions in 45 patients were included in the final analysis. ME-NBI and EUS had overall accuracies of 76.1% and 84.8%, respectively, in distinguishing mucosal from non-mucosal cancers. There were no differences between ME-NBI and EUS in terms of sensitivities and specificities in distinguishing mucosal from non-mucosal cancers (p = 0.500 and p = 0.688, respectively). When both ME-NBI and EUS suggested a mucosal depth of lesion invasion, the frequency of mucosal cancer in the final histopathology was 94%. However, if either ME-NBI or EUS suggested a non-mucosal depth of invasion, the frequency of mucosal cancer was only 21%.

CONCLUSION

ME-NBI and EUS are accurate predictors of SESCC invasion depth. If both methods suggest a mucosal depth of lesion invasion, the accuracy of the prediction is increased. Therefore, when possible, it would be better to evaluate the invasion depth of SESCC using both ME-NBI and EUS before deciding to perform endoscopic resection.

Clinicopathologic factors influencing the accuracy of EUS for superficial esophageal carcinoma

AIM: To identify clinicopathologic factors influencing the accuracy of a high-frequency catheter probe endoscopic ultrasonography (EUS) for superficial esophageal carcinomas (SECs).

METHODS: A total of 126 patients with endoscopically suspected SEC, who underwent EUS and curative treatment at Pusan National University Hospital during 2005-2013, were enrolled. We reviewed the medical records of the 126 patients and compared EUS findings with histopathologic results according to clinicopathologic factors.

RESULTS: A total of 114 lesions in 113 patients were included in the final analysis. The EUS assessment of tumor invasion depth was accurate in 78.9% (90/114) patients. Accuracy did not differ according to histologic type, tumor differentiation, tumor location, or macroscopic shape. However, accuracy significantly decreased for tumors ≥ 3 cm in size (P = 0.002). Overestimation and underestimation of the invasion depth occurred for 11 (9.6%) and 13 lesions (11.4%), respectively. In multivariate analyses, tumor size ≥ 3 cm was the only factor significantly associated with EUS accuracy (P = 0.031), and was specifically associated with the underestimation of invasion depth.

CONCLUSION: EUS using a high-frequency catheter probe generally provides highly accurate assessments of SEC invasion depth, but its accuracy decreases for tumors ≥ 3 cm.

A prospective comparative study of optical coherence tomography and EUS for tumor staging of superficial esophageal squamous cell carcinoma

BACKGROUND

The precise assessment of superficial esophageal squamous cell carcinomas (SESCCs) limited to the epithelium (EP) or lamina propria mucosa (LPM), the standard indication for endoscopic resection, is important to ensure good outcomes of endoscopic resection. With regard to tomographic imaging techniques, although the accuracy of EUS is practically insufficient, we previously demonstrated that high-resolution optical coherence tomography (OCT) might enable precise assessment for staging in a noninvasive and real-time manner.

OBJECTIVE

To clarify the accuracy of the preoperative staging of SESCCs by using OCT compared with that by using 20-MHz probe-type EUS.

DESIGN

A prospective study.

SETTING

An academic medical center.

PATIENTS

A total of 123 consecutive patients with 131 SESCCs were enrolled from May 2007 to September 2011.

INTERVENTIONS

A specialist examined the patients, by using both OCT and EUS, recorded a representative still image for each lesion, and reported the staging immediately after each examination. Another blinded investigator reviewed the recorded images and reported the staging independently. The histological staging was confirmed by the resected specimens. Finally, we calculated the accuracy of staging by using OCT and EUS.

MAIN OUTCOME MEASUREMENTS

The accuracy of OCT or EUS for EP/LPM.

RESULT

The accuracy for EP/LPM by using OCT was significantly higher than that by using EUS (OCT, 94.6%; HF-EUS, 80.6%; P < .05). Interobserver agreement of OCT and EUS was good and moderate, respectively.

LIMITATIONS

The small number of patients; a single-center, single-operator, nonrandomized, crossover study.

CONCLUSIONS

We prospectively demonstrated that the preoperative staging of SESCC by using OCT was more useful than that by using EUS.

Endoscopic ultrasound using ultrasound probes for the diagnosis of early esophageal and gastric cancers

Endoscopic ultrasound (EUS) devices were first designed and manufactured more than 30 years ago, and since then investigators have reported EUS is effective for determining both the staging and the depth of invasion of esophageal and gastric cancers. We review the present status, the methods, and the findings of EUS when used to diagnose and stage early esophageal and gastric cancer. EUS using high-frequency ultrasound probes is more accurate than conventional EUS for the evaluation of the depth of invasion of superficial esophageal carcinoma. The rates of accurate evaluation of the depth of invasion by EUS using high-frequency ultrasound probes were 70%-88% for intramucosal cancer, and 83%-94% for submucosal invasive cancer. But the sensitivity of EUS using high-frequency ultrasound probes for the diagnosis of submucosal invasive cancer was relatively low, making it difficult to confirm minute submucosal invasion. The accuracy of EUS using high-frequency ultrasound probes for early gastric tumor classification can be up to 80% compared with 63% for conventional EUS, although the accuracy of EUS using high-frequency ultrasound probes relatively decreases for those patients with depressed-type lesions, undifferentiated cancer, concomitant ulceration, expanded indications, type 0-I lesions, and lesions located in the upper-third of the stomach. A 92% overall accuracy rate was achieved when both the endoscopic appearance and the findings from EUS using high-frequency ultrasound probes were considered together for tumor classification. Although EUS using high-frequency ultrasound probes has limitations, it has a high depth of invasion accuracy and is a useful procedure to distinguish lesions in the esophagus and stomach that are indicated for endoscopic resection.

Staging of early adenocarcinoma in Barrett's esophagus

The main goal in the staging of patients with early neoplasia arising in the context of Barrett's esophagus (BE) is to identify individuals who are eligible for endoscopic therapy and differentiate them from those who require surgical management. To make the proper patient selection a combined staging strategy consisting of endoscopy evaluation, endoscopic ultrasonography, and endoscopic mucosal resection is necessary. In this article, the authors summarize the evidence behind each different staging modality in the setting of early BE adenocarcinoma and propose a staging approach that helps to select patients who are suitable for endoscopic therapy.

Optimal endoluminal treatment of Barrett's esophagus: integrating novel strategies into clinical practice

Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.

Endosonography of high-grade intra-epithelial neoplasia/early cancer

Endosonography (EUS) is frequently used for staging of early malignant gastrointestinal lesions. High-grade intra-epithelial neoplasia (HGIN) and mucosal cancer have a very low risk for lymphatic metastasis and therefore are suitable for endoscopic therapy. In HGIN and early oesophageal and gastric cancer, high-frequency miniprobes can provide detailed imaging of the different layers. However, diagnostic accuracy differentiating between mucosal and submucosal disease is not sufficient, and therefore (diagnostic) endoscopic resection should be performed in all localisable lesions to detect submucosal cancer at risk for lymph node metastasis. EUS for lymph node staging is considered to be the method with the highest accuracy, especially compared with computed tomography.

Magnifying endoscopy with narrow band imaging for predicting the invasion depth of superficial esophageal squamous cell carcinoma

The invasion depth of superficial esophageal squamous cell carcinoma is important in determining therapeutic strategy. The aim of this study was to prospectively investigate the clinical utility of magnifying endoscopy with narrow band imaging compared with that of non-magnifying high-resolution endoscopy or high-frequency endoscopic ultrasonography in predicting the depth of superficial esophageal squamous cell carcinoma. The techniques were carried out in 72 patients with 101 superficial esophageal squamous cell carcinomas, which were then resected by either endoscopic mucosal resection or esophagectomy. The histological invasion depth was divided into two: mucosal or submucosal carcinoma. We investigated the relationship between endoscopic staging and histology of tumor depth. Non-magnifying high-resolution endoscopy, magnifying endoscopy with narrow band imaging, and high-frequency endoscopic ultrasonography had overestimation/underestimation rates of 7/5, 4/4 and 8/3%, respectively. The sensitivity rates for the three techniques were 72, 78, and 83%, respectively, and the specificity rates were 92, 95, and 89%, respectively. There were no statistically significant differences among the three endoscopic techniques. Clinical utility of magnifying endoscopy with narrow band imaging does not seem to be significantly different from that of non-magnifying high-resolution endoscopy or high-frequency endoscopic ultrasonography in predicting the depth of superficial esophageal squamous cell carcinoma. Magnifying endoscopy with narrow band imaging may have potential to reduce overestimation risks of non-magnifying high-resolution endoscopy or high-frequency endoscopic ultrasonography.

Role of endoscopic ultrasound in superficial esophageal cancer

The recent increase in the incidence of superficial esophageal cancer and promising developments in potentially curative endoscopic therapies have placed endoscopic ultrasound in a central position with regard to decision making. This is a review of the literature to determine the role of endoscopic ultrasound and high frequency probe ultrasonography in the assessment of superficial esophageal carcinomas.